Hydromorphone vs Prochlorperazine/Diphenhydramine for Acute Migraine Pain Relief

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Sustained relief from headache within 2 hours of treatment was the study’s primary outcome.
Sustained relief from headache within 2 hours of treatment was the study’s primary outcome.

Intravenous (IV) treatment with hydromorphone was found to provide less pain relief for acute migraine than IV prochlorperazine in patients admitted to the emergency department, according to a study published in Neurology.

Investigators evaluated pain relief outcomes in 127 patients with acute migraine admitted to 2 emergency departments in New York City. All parties involved — including investigators, patients, clinicians, and research personnel — were blinded during the treatment phase of this study.

Patients were randomly assigned to receive IV hydromorphone (1 mg; n=64), or IV prochlorperazine (10 mg) plus diphenhydramine (25 mg; n=62). Diphenhydramine was administered in the prochlorperazine group for the prevention of akathisia. Sustained relief from headache within 2 hours of treatment was the study's primary outcome.

After therapy, 37 (60%) patients in the prochlorperazine group achieved the primary outcome vs 20 (31%) in the hydromorphone group (difference 28%; 95% CI, 12-45; number needed to treat [NNT], 4; 95% CI, 2-9). In addition, sustained headache relief after 1 or 2 medication doses was achieved in 37 (60%) patients receiving prochlorperazine and in 26 (41%) patients receiving hydromorphone (difference, 19%; 95% CI, 2-36; NNT, 6; 95% CI, 3-52).

The study did not include participants with a history of prochlorperazine or hydromorphone use, which may limit the overall findings. In addition, patients who met criteria for analgesic overuse were included.

Although these findings demonstrate greater pain relief from acute migraine with prochlorperazine compared with hydromorphone, the investigators suggest their data “do not provide a rationale to avoid hydromorphone for patients with a history of nonresponse to antidopaminergics.”

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Reference

Friedman BW, Irizarry E, Solorzano C, et al. Randomized study of IV prochlorperazine plus diphenhydramine vs IV hydromorphone for migraine [published online October 18, 2017]. Neurology. doi: 10.1212/WNL.0000000000004642

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